Review the release of information forms attached to this assignment. If you have one from your place of employment, feel free to substitute that for one of those attached. If you select a for from y

Willapa Harbor Hospital PO Box 438, South Bend, WA 98586 Phone: 360-875-5526 Fax: 875-0592 AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION I request and authorize Willapa Harbor Hospital to release medical records for: ____________________________________________________________________________________ Patient Date of Birth Medical Record # To the following: Name: _______________________________________________________________________ Address: _______________________________________________________________________ For the purpose of: [ ] Continuity of care. [ ] Other: _______________________________________________________________________ This request and authorization applies to: [ ] All healthcare information [ ] Specific healthcare information as indicated: ________________________________________ By INITIALING, I specifically authorize the release of the following confidential information: _____ HIV test, test results and related information including high-risk behavior documentation. _____ Drug/Alcohol diagnosis, treatment, or referral information. _____ Mental Health treatment information. _____ Other (specify): ________________________________________________________________ This authorization is valid for 90 days from the date of signature unless cancelled by written notice by the patient/legal guardian. ______________________________________ ___________________________________ Signature of patient or legal guardian Relationship to patient ___________________________________ ____________________________________ Witness Date OFFICE USE ONLY HAS THE HEALTHCARE INFORMATION BEEN RELEASED? _____NO _____YES SIGNATURE OF STAFF RELEASING INFORMATION: __________________________________________